World J. Surg. 16, 1193-1201, 1992

World Journal of Surgery © 1992 by the Soci~t~ lnternationale de Chirurgie

Present Status of Sclerotherapy and Surgical Treatment for Esophageal Varices in Japan Yasuo Idezuki, M.D., F . A . C . S . and the Japanese Research Society for Portal H y p e r t e n s i o n and Japanese Research Society for Sclerotherapy o f Esophageal Varices Second Department of Surgery, Faculty of Medicine, University of Tol~yo,Tokyo, Japan A nationwide survey on the treatment for esophageal varices was performed in 1990 jointly by the Japanese Research Society for Portal Hypertension and the Japanese Research Society for Sclerotherapy of Esophageal Varices to clarify the present status and strategy of this treatment in Japan. A total of 12,675 cases, including 4,159 cases of nonshanting procedures and 7,612 cases of sclerotherapy, were collected from 101 institutions. The number of patients had greatly increased in the first half of the 1980s. With regard to the therapeutic strategy, surgical procedures were not recommended in either emergency or prophylactic cases in terms of the timing of the operation, or in Child C cases in terms of the degree of hepatic insufficiency. Endoscopic injection sclerotherapy became the leading method of treatment and in 1988 only 16% of 1,528 cases were treated by surgical procedures. The strategy for the same group of patients differed between medical and surgical institutions. With regard to sclerotberapy, repeated intravariceal injection and combined intra- and paravariceal injection were the two main techniques and 10-year cumulative survival rates were 62.8% in Child A cases, 47.7% in Child B eases, and 13.2% in Child C cases. With regard to surgical procedures, 10-year survival rates were 50.6% in esophageal transection, 42.5% in gastric transection, 53.1% in cardiectomy, and 43.0% in selective shunt procedures. We are quite convinced that this report will prove useful in determining the future strategy for treating esophageal variees.

The treatment for bleeding esophageal varices is important in improving the prognosis of patients with portal hypertension. A number of therapeutic modalities have been proposed for this clinical entity. The most suitable procedure should be selected, considering a wide variety of underlying liver disease, different grades of liver dysfunction, the diversity of collateral distribution, and the difference in timing of treatment. The Japanese Research Society for Portal Hypertension was founded in 1967 and has during its short history produced a number of achievements: developing the portal non-decompression surgery [1], investigating the adequacy of prophylactic surgery [2], and establishing the general rules for recording the endoscopic findings of esophageal varices [3]. The surgical procedures had been the leading methods of treatment for esophageal varices until the end of the 1970s. However, the Reprint requests: Yasuo Idezuki, M.D., F.A.C.S., Professor and Surgeon in Chief, Second Department of Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113, Japan.

more recent development of endoscopic injection sclerotherapy using a flexible fiberoptic endoscope and new sclerosants has been remarkable. This technique was introduced to Japan in 1977 and greatly altered the strategy for managing esophageal varices. The Japanese Research Society for Sclerotherapy of Esophageal Varices was founded in 1986 and continues to be active in further developing injection sclerotherapy. Pertinent issues concerning sclerotherapy, such as the indication for sclerotherapy, prospective technical improvements, and the mechanism underlying sclerosant action, have been under ongoing study. The nationwide survey on endoscopic injection sclerotherapy was conducted twice by this society in 1986 and 1988 [4-61. In 1990 a nationwide survey on not only endoscopic selerotherapy but surgical therapy for esophageal varices was jointly conducted by the Japanese Research Society for Portal Hypertension and the Japanese Research Society for Sclerotherapy of Esophageal Varices to further clarify the current status and refine strategies utilized in Japan. We herein present the results of this survey. The data gathered and summarized will clearly be of great value in determining the treatment of choice for patients with esophageal varices. Materials and M e t h o d s

The questionnaire was sent to 156 institutions registered with the Japanese Research Society for Portal Hypertension or with the Japanese Research Society for Sclerotherapy of Esophageal Varices, and of these, 101 institutions returned completed forms. Data on the treatment for esophageal varices performed before May 30, 1990 were collected. A total of 12,675 cases, including 4,159 cases of non-shunting procedure, 607 cases of selective shunt operation, 197 cases of portacaval shunt, and 7,612 cases of sclerotherapy were evaluated in this study. More than 90% of patients had liver cirrhosis, and the rest presented with idiopathic portal hypertension (IPH), extrahepatic portal obstruction (EHPO), and other diseases. Mean follow-up in sclerotherapy cases, nonshunting operation cases, and selective shunt cases were 3.09 +- 0.37, 4.50 +- 0.89 and 4.65 +-- 1.29

1194

World J. Surg. Vol. 16, No. 6, Nov./Dec. 1992

No. of patients

Operation Sclerotherapy

2000-

Sclero,-kOp. Case by case

Sl I}I!i;]}I;]}~}}7}7}}}}};~:~I~XX/XXX/'.X.~S/XX/AI

0 Others

1500-

Child B

~J~lill///llllJiiiiIil/lll/llll/llli/lll/llil/lllli~,

MI ~

J

~

/

"

/

~

0

:~

/I

1

bI

1000L ~ l / / / i / l l / / / l l l , ~ : ~

Child C

~

500-

pe ~tl.v,o: hunt

MI ~

/

0

/

20

i

I

1

II

i

60 Sh Surgical Institutions Mh Medical Institutions

i

1983 1984 1985 1986 1987 1988 year

Fig. 1. Annual number of patients treated for esophageal varices,

0

~

40

i:i:~:i:!:i:i:~:~:i:Nonlhunting op~rat on~iiiii~i ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ========================== 1

,+;,f

.....................

s,

Fig. 2. Strategy for treating esophageal varices in emergency cases.

Operation

years, respectively. Cumulative survival rates were calculated according to the Kaplan-Meier formula. Child A

Sclerotherapy

ScleromkOp. / v/Case by case

st

liiii{iiiiiiiliiiiii;!iliiiiiiiiiiiiiiiiiiiiiiiiiiiiili(ii!;iii~iiiiiV/S////A 1 0

MI

lii'~iiiiiiili~~~

R ~

Annual Number of Patients The annual number of patients increased rapidly in the first half of the 1980s. This was mainly due to the increase in the number of patients treated by sclerotherapy, The number of surgical treatments was reduced during the same period (Fig. 1). In contrast, the annual number of patients was 1,535 in 1986, 1,557 in 1987, and 1,528 in 1988. These figures in the second half of the 1980s were relatively stable and the proportions of surgical treatment were also stable, ranging from 16% to 18%.

Child B

St Ei!iiii!~iTililiiiiiiiiii{~i{~i~/X~ I ~~///////////////////~

0

~~/i/////I/J~/J/Ti/////////////I

sn ~ Child C

S

/

/

[/~/#////////////////i/1

MI ~ I

o

/

io

/

/

~

~

4'0

O ................

e'o Sh Surgical Institutions Mh Medical Institutions

Fig. 3. Strategy for treating esophageal varices in elective cases.

Therapeutic Strategy for Esophageal Varices The strategy for treating esophageal varices was investigated depending on the timing of treatment and the severity of liver dysfunction. Treatment timing included emergency, elective, and prophylactic. Liver function was stratified into three groups based on the Child classification.

gical procedures were indicated at higher rates in surgical institutions than in medical institutions. However, as far as Child C cases were concerned, operation was offered only in a few surgical institutions as the first treatment modality (Fig. 3).

Strategy in Prophylactic Cases. Prophylactic treatment was Strategy in Emergency Cases. Emergency operation was considered as the first treatment of choice in surgical institutions in 24% of Child A cases, in 17% of Child B cases, but in no Child C cases. Conversely in medical institutions operation was not regarded at all as the initial treatment in any liver function group (Fig. 2). Sclerotherapy was widely selected in emergency cases, especially in patients with poor liver function. Emergency surgery was selected in a group of Child A and Child B cases in surgical institutions but was the last choice in Child C cases in both medical and surgical institutions. Balloon tamponade was used at 77.3% to 81.8% of surgical institutions and at 60.7% to 75.0% of medical institutions to achieve temporary hemostasis and to improve the general condition prior to undergoing the more definitive treatment.

Strategy in Elective Cases. The strategy in elective cases greatly differed between surgical and medical institutions. Sur-

indicated in general when risky varices were identified by endoscopic examination. A red color sign, size of varices, and prognostic blue varices were reported to be of value in predicting variceal bleeding [7, 8]. In this survey, 94.5% of the institutions considered a positive red color sign as a criterion for prophylactic treatment. Operation was the first choice of therapy in 42% of Child A cases and 27% of Child B cases in surgical institutions, whereas this was so in only 11% of Child A cases and 7% of Child B cases in medical institutions. In prophylactic Child C cases, operation was not indicated as the initial therapy in either surgical or medical institutions (Fig. 4). In medical institutions the strategy for elective cases was almost identical to that for prophylactic cases. In surgical institutions, on the other hand, operative treatment was selected at a higher rate in elective cases than in prophylactic cases.

Y. Idezuki et ai.: Sclerotherapy for Esophageal Varices

Operation

Child A si M~

Sclero.-kOp. Sclerotherapy / Case by case

~liiii!~x///////////////,, iiiilii:'ilililili[~iii~i~ii[iff////~//////~l~,~

~I~No treatment

[iiiiii74ii~//~///////Y//A

.....[)

Child B M~ ~ i ! ~ / / / / / / / / / / / / / / / / / / / ~

0

~~/////////////////////////TJ///J

"~1

s,

Child

C M, ~

I'

o

P

~ ......4b

"

6'o

0 t Sh Surgicat Institutions Mi: Medical Institutions

Fig. 4. Strategy for treating esophageal varices in prophylactic cases.

1195 Table 1. Sclerosing agents used for sclerotherapy.

Average volume (range) (ml) Sclerosing agents Ethanolamine oleate (EO) Polydocanol (AS) EO + AS Sodium tetradecyl sulfate Ethyl alcohol Others (Thrombin, 50% glucose)

No. of institutions

Per single varix

Per single therapy

34

5.7 (1.3-15)

12.7 (2-29)

8 24 2

4.0 (0.7-15)

13.2 (2-40)

6.1 (5-7.2)

12.4 (10-15)

1 9

1.9 (0.5-4)

4.3 (2.5--8)

Table 2. Mortality and morbidity associated with sclerotherapy. Complication

A general trend arose in that surgical procedure was not recommended in either emergency or prophylactic cases in terms of the timing of operation, or in Child C case in terms of the degree of hepatic insufficiency. Furthermore, endoscopic injection sclerotherapy had become the most popular method of treatment in patients with esophageal varices. It should be noted, however, that the choice of elective surgery had slightly increased both in medical and surgical institutions during the more recent years.

Indication for and Technique of Sclerotherapy The results of this survey show that sclerotherapy was performed 26,208 times on 7,612 patients prior to May 30, 1990. The average number of scterotherapy treatments per patient was 3.5, ranging from 1 to as many as 18 treatments. In view of the timing of treatment, 7,612 patients were divided into three groups: 25.2% for emergency cases, 27.0% for elective cases, and 47.8% for prophylactic cases. In operation cases, the statistics were 12.1% for emergency cases, 51.7% for elective cases, and 36,2% for prophylactic cases. It is clear that the percentage of prophylactic sclerotherapy was much higher than that of prophylactic surgery. With regard to the technique of sclerotherapy, intravariceal injection, paravariceal injection, and combined intra- and paravariceal injection were intended in 39.6%, 7.1%, and 38.8% of all cases, respectively. The rest of 14.5% cases were unknown or no reply. Sclerotherapy is usually performed using a flexible endoscope under pharyngeal topical anesthesia and sedation with minor tranquilizer in Japan. Sclerosing agents used in sclerotherapy are summarized in Table 1. Ethanolamine oleate continues to be the leading sclerosant used in Japan. However, combined use of ethanolamine oleate and polydocanol has greatly increased. This use closely relates to the widespread application of the combined intra- and paravariceal injection technique. Other sclerosants used as the sole agent or as one agent in combination in several institutions were sodium tetradecyclosulfate (TSS), ethyl alcohol, thrombin and 50% glucose.

Esophagus Ulceration Bleeding from ulcer Perforation Stricture Bleeding from varices Bleeding from peptic ulcer Respiratory system Pleural effusion Pulmonary embolism Pneumonia Chest pain Shock Disseminated. iutravascular coagulation Fever Septicemia Portal vein thrombosis Hepatic failure Renal failure Cerebrovascular system Others Total

No. of pts. (%)

No. of fatalities

2,219 (30.6) 125 (1.7) 25 (0.3) 282 (3.9) 43 (0.6) 158 (2.2)

0 8 12 0 1 2

375 (5.2) 13 (0.2) 27 (0.4) 1,560 (21.5) 146 (2.0) 32 (0.4)

0 4 7 0 3 5

1,646 (22.7) 7 (0.1) 25 (0.3) 107 (1.5) 55 (0.8) 27 (0.1) 300 (4.1) 7,172

0 3 5 28 5 1 4 88

Results of Sclerotherapy A considerable variety of complications associated with sclerotherapy were observed. Some were insignificant and did not warrant treatment whereas others were serious enough to be fatal (Table 2). Esophageal ulceration, fever, and chest pain were the three most common but not serious complications. Esophageal ulcers were frequently caused following the paravariceal injection, and the opinion prevailed that this kind of ulceration was necessary or innevitable process in the eradication of esophageal varices. From this point of view, esophageal ulcers could not be regarded as a complication but rather as an outcome of the normal course. Eighty-eight (1.2%) of 7,112 patients died in connection with sclerotherapy. The major causes of death were hepatic failure and esophageal perforation. Importantly, 49 of these 88 deaths were emergency cases. The mortality rates of sclerotherapy were calculated as 49 (2.6%) of 1,910 emergency cases, 29

1196

World J. Surg. Vol. 16, No. 6, Nov./Dec. 1992

Table 3. Variceal bleeding following sclerotherapy relative to liver

diseases and liver function.

% 100 T ' ~ , _ .

Disease

No. of pts.

Variceal bleeding (%)

Cirrhosis Child A Child B Child C IPH EHPO

6,581 1,841 3,085 1,655 158 35

903 (13.7) 124 (6.7) 318 (10.3) 461 (27.9) 11 (7.0) 4 (11.4)

IPH: Idiopathic portal hypertension; EHPO: Extrahepatic portal obstruction.

~ ~--

8O

Child A(n=2001) 60-

L...,

J1

=I t....

Results of Surgical Procedures Among the surgical procedures performed for esophageal varices, portal nondecompression surgery was widely performed in

""1

L= Child B(n=2987)

[ ....

40 -

! |---I

='-",

20-

(1.3%) of 2,312 elective cases, and 10 (0.3%) of 2,950 prophylactic cases. Bleeding from the gastrointestinal tract after sclerotherapy was observed in 1,359 (17.9%) of 7,612 patients. Bleeding of 67.5% was from recurrent esophageal varices and 10.0% was from gastric varices. Other bleeding resulted from gastritis (9.5%), peptic ulcer (3.8%), esophageal ulcer (4.4%), and unknown causes (6.6%). Bleeding from esophageal and gastric varices, respectively, occurred in 18.5% and 3.6% of 1,915 emergency cases, in I4.1% and 1.6% of 2,057 elective cases, and in 6.7% and 1.0% of 3,640 prophylactic cases. Recurrent bleeding occurred at higher rates in emergency cases than in elective cases. Hemorrhage from varices after prophylactic sclerotherapy was observed at higher rates than expected. The incidence of variceal bleeding after sclerotherapy is presented in Table 3 relative to the underlying liver disease and liver function. There was a clear tendency for recurrent varices to bleed at a higher rate commensurate with the severity of liver dysfunction. The 5-year and 10-year cumulative survival rates following sclerotherapy in terms of the timing of treatment were, respectively, 46.2% and 29.2% in 1,889 emergency cases, 56.8% and 42.3% in 1,851 elective cases, and 63.3% and 46.8% in 3,476 prophylactic cases. There was no significant difference between these figures. The 5-year and 10-year cumulative survival rates following sclerotherapy regarding the underlying liver disease were, respectively, 56.1% and 40.8% in 6,949 cases with liver cirrhosis, 79.6% and 58.0% in 203 cases with idiopathic portal hypertension (IPH), and 88.5% and 88.5% in 64 cases with extrahepatic portal obstruction (EHPO). The 5-year and 10-year cumulative survival rates following sclerotherapy relative to liver function were, respectively, 81.1% and 62.8% in 2,001 Child A cases, 61.4% and 47.7% in 2,987 Child B cases, and 26.2% and 13.2% in 2,164 Child C cases (Fig. 5). The survival rates decreased as a matter of course as the severity of liver dysfunction increased. Among 7,612 patients who underwent selerotherapy, 2,622 (34.4%) died before May 30, 1990. The cause of death was liver failure (44.1%), hepatoma (26.0%), variceal hemorrhage (13.8%), gastrointestinal tract bleeding (3.5%), and sclerotherapy complications (1.8%).

i

I,.. Child C(n=2164) 0

.......

0

1

I

2

4

"

1

1'"'

t

6

8

10

years

Fig. 5. Cumulative survival curves following sclerotherapy relative to liver function. No. of patients 500[ ] Nonshunting op. [ ] Selective shunt op. [ ] Shunt op.

400"

300"

200"

100

0

i

1983

1984

i

1985

i

1986

i

1987

i

1988 year

Fig. 6. Annual number of patients treated by nonshunting operation, selective shunt operation, and portal decompression surgery.

Japan (Fig. 6). This procedure included the nonshunting direct interruption operation and the selective shunt operation. The nonshunting operation consisted of transecting the gastrointestinal tract in addition to splenectomy and devascularization around the lower esophagus and upper stomach. This procedure was divided into esophageal transection, gastric transection, cardiectomy, and devascularization with splenectomy alone (Hassab's procedure) depending on the manner of transection. Esophageal transection was further subdivided with regard to the approach: transthoracic, transthoracophrenic, transtboraeoabdominal (Sugiura), and transabdominal. Transabdominal esophageal transection included mechanical reconstruction by autosuture apparatus and manual suturing. Cardiectomy was also further subdivided into the transthoracophrenic approach and the transabdominal approach. Selective shunt procedures included distal splenorenal shunt (DSRS: Warren) and left gastric venocaval shunt (LGV: Inokuchi) [9]. Splenopancreatic disconnection (SPD) and/or gastric

Y. Idezuki et al.: Sclerotherapy for Esophageal Variees

1197

Table 4. Clinical results of surgical procedures.

Operative procedure Esophageal transection Gastric transection Cardiectomy Devascularization with splenectomy Selective shunt Portal decompression surgery Others

Cumulative survival No. of Operative Rebleeding rates pts. death (%) (%) (5-yr/10-yr) 2,652 215 (8.1) 204 (7.7) 65.9/50.6 261 618 628

39 (14.9) 52 (8.4) 45 (7.2)

52 (19.9) 63 (10.2) 51 (8.1)

56.4/42.5 65.3/53.1 64.5/51.4

607 211

20 (3.3) 34 (16.1)

41 ( 6 . 8 9 (4.3)

57.1/43.0

97

13 (13.4)

7 (7.5)

Table 5. Operative mortality depending on timing of operation.

Operative procedure Emergency (%) Elective (%) Prophylactic (%) Esophageal transection Gastric transection Cardiectomy Devascularization with splenectomy Selective shunt Portal decompression surgery Others

288 (27.8)

1351 (5.8)

1013 (5.6)

30 (20.0) 91 (25.3) 31 (41.9)

150 (16.0) 394 (6.3) 255 (9.4)

81 (11.1) 133 (3.0) 342 (2.3)

105 (3.8) 26 (30.8)

329 (3.3) 115 (7.8)

173 (2.9) 59 (27.1)

41 (31.7)

24 (0)

32 (0)

disconnection (GD) were added to DSRS to facilitate the variceal decompression with higher selectivity [10, 11]. The number of cases, operative mortality, rebleeding rates, and 5-year and 10-year cumulative survival rates for these surgical procedures are listed in Table 4. Among the nonshunting operations, esophageal transection was most widely performed in Japan. Higher operative mortality rates were observed in emergency cases as compared with elective and prophylactic cases. It should be noted, however, that mortality rates were not so low even in prophylactic cases (Table 5). Rebleeding rates after esophageal transection were 7.6% in emergency cases, l 1.1% in elective cases, and 3.2% in prophylactic cases. Esophageal transection met with the best results regarding rebleeding rates among the nonshunting procedures (Table 6). On the other hand, selective shunt operations produced excellent results concerning rebleeding as compared with nonshunting operations. Bleeding is also noted to have occurred at remarkably high rates following prophylactic operations. The rebleeding rates of nonshunting procedures tended to increase in proportion to the grade of liver dysfunction. Conversely, the rebleeding rates of selective shunt operations were not so high even in Child C cases (Table 7). Selective shunt procedures can be said to be superior to nonshunting operations as far as rebleeding rates are concerned. Cumulative survival curves following esophageal transection and other nonshunting operations are illustrated in Figure 7 and Figure 8, respectively. All nonshunting operations except for transthoracic esophageal transection presented similar survival curves. Survival following transthoracic esophageal transection was poor because this procedure was often performed on

Table 6. Rebleeding rates of surgical procedures depending on timing of operation.

Operative procedure

Emergency

Elective

Prophylactic

Esophageal transection Gastric transection Cardiectomy Devascularization w i t h splenectomy Selective shunt Portal decompression surgery

7.6% 16.7% 14.3% 29.0%

11.1% 28.0% 10.9% 9.4%

3.2% 6.2% 3.8% 5.3%

3.8% 3.8%

9.4% 6.1%

3.5% 1.7%

high-risk patients or as an emergency operation. The cumulative survival curve in emergency cases following transabdomihal esophageal transection, as a representative of nonshunting procedures, demonstrated a poorer result in comparison with elective and prophylactic cases (Fig. 9). Cumulative survival curves following transabdominal esophageal transection with respect to liver function are given in Figure 10. Naturally, a poorer result was observed in proportion to worsening liver function. Cumulative survival curves following selective shunt operations are summarized in Figure 11. Survival curves subsequent to DSRS with sptenopancreatic disconnection (SPD) and DSRS with SPD and gastric disconnection (GD) appear to be slightly superior to those following distal splenorenal shunt (DSRS) and left gastric venocaval shunt (LGV). Further follow-up is, of course, necessary to clarify these points. Discussion

Surgical operations were the main stream in the field of treating esophageal varices prior to the reintroduction of endoscopic injection sclerotherapy. Portal nondecompression surgery was widely performed in Japan, while shunt surgery was the leading procedure undertaken in Western countries. The introduction of sclerotherapy greatly altered the management strategy for esophageal varices. After only a very few years, sclerotherapy became the most popular treatment of choice at many centers worldwide. One of the reasons for this widespread use of sclerotherapy was that physicians or endoscopists could participate directly in the treatment, whereas before they could only diagnose the condition and send the patient to the surgical division. Now sclerotherapy has become a standard technique for both physicians and surgeons in almost all hospitals. The extended application of prophylactic sclerotherapy could account for the rapid increase in the patient number in the first half of the 1980s in this survey, because the actual number of patients with portal hypertension could not be assumed to change dramatically. The strategy for treatment of esophageal varices both in medical and surgical institutions in 1990 changed significantly compared with the strategies employed in 1986 and 1988. Three major points underlying these changes are: 1) the indication for emergency and prophylactic surgery had decreased both in medical and surgical institutions, 2) surgery was not considered to be the first treatment of choice in patients with poor liver function, and 3) the choice of elective surgery had slightly increased. To elucidate the reasons for these strategic changes, we

1198

World J. Surg. Vol. 16, No. 6, Nov./Dec. 1992

Table 7. Rebleeding rates following surgical procedures depending on liver disease and liver function.

Nonshunting procedure

Selective shunt procedure

Disease

No. of pts.

No. of rebleeding (%)

No. of pts.

No. of rebleeding (%)

Cirrhosis Child A Child B Child C IPH EHPO Others Total

3,569 1,321 1,568 680 736 154 61 4,520

275 (7.7) 91 (6.9) 116 (7.4) 68 (10.0) 44 (6.0) 11 (7.1) 8 (13.1) 338 (7.5)

428 185 160 83 53 2 1 484

24 (6.0) 9 (5.2) 11 (7.5) 4 (4.9) 2 (3.8) 0 0 26 (5.4)

IPH: Idiopathic portal hypertension; EHPO: Extrahepatic portal obstruction.

% 100-~.=

% 10080-

'--'1 1"-I--~---t...-

60-

Prophylactin(n=415)

i===--t

.... I 40-

L

b''°~..,

Etective(n=560)

e 0...~

.... k..., . . . . . . . . . . . . .

Emergency(n=86)

200

I

I

I

I

I

2 4 6 8 10 years 0 Fig. 9. Cumulative survival curves following esophageal transection via transabdomioal approach with respect to timing of operation.

e04t

I! (n--"321) 1 0 0 • [... ~ - ~ " • ~'-l . ~~,-- - -~~ _ ~ _ Transthoracophrenic 60L"I ~ Transabdominal(n: 1061) ,

~

/,--

.

" " ----~ Transthoracoabdominal(n=871) " . . . . . -,.... ,-- Transthoracic(n=421)

a. ~u20-

q~ , . . j L-~=" i._ ~..._ ~._. ~... ~,.. _ _ .t. "

80-

Child A(n=558)

: 60- L, - - - i

I

I

:

'i

,

i

0

I

; ' " l L...!

40-

L. Child B(n=401)

0

b...

Fig. 7. Cumulative survival curves following esophageal transection depending on surgical approach.

% 10080-

|

'

"''ql I

Gastric transection(n=331)

L . . . ~

. , Transthoracophrenic "'-"~"I Cardiotomy(n= 13)

Child C(n=102)

•--

O _.__

I

20-

I

I

I

I

2

4

6

8

I

10 years

Fig. 10. Cumulative survival curves following esophageal transection via transabdominal approach considering liver function.

and 5.6% in prophylactic cases. Notably, the mortality rate following prophylactic operations was not low enough. It is 60obvious from the data that endoscopic sclerotherapy was superior to esophageal transection with regard to the mortality rate and the risk of treatment. splenectomy(n =539) Cardiotomy(n =539) The bleeding rates from varices following sclerotherapy and esophageal transection were, respectively, 22.3% and 7.6% in emergency cases, 15.7% and 11.1% in elective cases, and 7.6% 2 and 3.2% in prophylactic cases. The bleeding rates following sclerotherapy and nonshunting operations were, respectively, 6.7% and 6.9% in Child A cases, 10.3% and 7.4% in Child B I I I I I 2 4 6 8 10 years 0 cases, and 27.9% and 10.0% in Child C cases. A major difference in rebleeding rates was observed in emergency cases and Fig. 8. Cumulative survival curves following nonshunting procedures. Child C cases. The reason for this was that sclerotherapy could be applied to Child C cases or emergency cases in which attempted to compare the results of sclerotherapy with those of operations were not indicated because of the poor risk. Surgery can thus not be said to be superior to sclerotherapy in emersurgical procedures, although these data were not generated from a controlled study. The mortality rates of sclerotherapy gency or Child C cases. and esophageal transection were, respectively, 2.6% and 27.8% The 5-year/10-year cumulative survival rates following sclerotherapy and transabdominal esophageal transection were, in emergency cases, 1.5% and 5.8% in elective cases, and 0.3%

!t

Y. ldezuki et al.: Sclerotherapy for Esophageal Varices

%

100~_

institutions. Further experience will be necessary in an effort to reach a common standard strategy at all institutions. We are confident that this report will prove useful in determining the future strategy for treating esophageal varices.

I

DSRS+SPO(n=m) ~---~ . . . . . . ~ . .

40-

t.GV(n=5-~) "'" DSRS(n=278)

20-

0

0

I

2

I

4

1199

~i

I

8

1~0 years

Fig. 11. Cumulative survival curves following selective shunt procedures. DSRS: Distal splenorenal shunt; SPD: Splenopancreatic disconnection; GD: Gastric disconnection; LGV: Left gastric venocaval shunt.

respectively, 46.2/29.2% and 29.9/25.3% in emergency cases, 56.8/42.3% and 71.4/50.3% in elective cases, and 63.3/46.8% and 71.2/69.1% in prophylactic cases. It can be said that sclerotherapy was the first treatment of choice in emergency cases and that the cumulative survival rates of transabdominal esophageal transection in some elective cases were superior to those of sclerotherapy. An operative procedure can be recommended in a certain group of elective cases, after considering that repeated sclerotherapy needed a longer treatment time than the operation. The 5-year/10-year cumulative survival rates following sclerotherapy and transabdominal esophageal transection were, respectively, 81.1/62.8% and 81.3/73.0% in Child A cases, 61.2/47.7% and 59.1/44.4% in Child B cases, and 26.2/9.3% and 26.1/11.2% in Child C cases. These survival rates were primarily determined relative to liver function regardless of the treatment of choice. In conclusion, it can be said that the recent changes in strategy were based on these clinical results. The multiplicity of the grades and location of esophageal varices and the variety of underlying liver diseases and liver function suggest that no single treatment can be ideal for all pafiems in all clinical circumstances. Although sclerotherapy can be applied to a large group of patients, surgery should be reserved for those patients who can expect superior results by operation or who did not respond well to sclerotherapy. More efforts should be directed toward defining the group of patients who are capable of a good outcome through surgery. Combined treatment of sclerotherapy and surgery, for example, the combination of sclerotherapy and Hassab's procedure, can be considered to be another treatment of choice. In addition, liver transplantation should be regarded as one of the treatment modalities for patients with esophageal varices, especially for patients with poor liver function [12]. Although, unfortunately for the patients, cadaver donor liver transplantation was not officially accepted in Japan at the time these data were assessed; this option should be added to the treatments of choice in the near future. It was curious that the strategy for the same group of patients with esophageal varices differed between medical and surgical

R~sum~

Une 6tude nationale a 6t6 conduite en 1990 par la Japanese Research Society for Portal Hypertension et la Japanese Research Society for Sclerotherapy of Esophageal Varices pour 6valuer l'rtat actuel de ce traitement et ses indications au Japon. Au total, 12675 cas, dont 4159 traiters par des procrdrs sans drrivation chirurgicale et 7612 cas traitrs par scMroth6rapie ont 6t6 colligrs dans 101 institutions. Le nombre de patients a augment6 beaucoup dans la premiere moiti6 de le drcennie 1980. La chirurgie a ~t6 drconseillre en cas d'urgence, pour les patients Child C ou comme intervention prophylactique. A partir de 1988, la sclrrothrrapie est devenue la technique de rrfrrence et seulement 16% des 1528 cas traitrs dans cet intervalle l'ont 6t6 par la chirurgie. L'attitude thrrapeutique a beaucoup diffrr~ selon qu'il s'agissait d'une unit6 de soins m6dicale ou chirurgicale. Eu 6gard ~t la sclrrothrrapie, l'injection intravariqueuse r~prtre ou l'injection intra et paravariqt~euse eombir~e oat 6t6 les fleux principales techniques employres. La survie cumulative a 6t6 respectivement de 62.8%, de 47.7% et de 13.2% scion qu'il s'agissait de patients des stades Child A, B ou C. Eu 6gard des procrdrs chirurgicaux, la survie A 10 ans a 6t6 de 50.6% en cas de trans-section esophagienne, de 42.5% en cas de rrsection gastrique, de 53.1% en cas de rrsection emportant le cardia et de 43% eta cas de shunts portocaves srlectifs. Nous sommes convaincus que les rrsultats de cette 6tude serait utiles pour drterminer la stratrgie thrrapeutique dans les varices esophagiennes. Resumen

En el afio 1990 se realiz6 una investigaci6n nacional sobre el tratamiento de las v~irices esof~igicas conjuntamente por la Sociedad Japonesa de Investigacirn en Hipertensirn Portal y la Sociedad Japonesa de Investigacirn en Escleroterapia para V~ices Esof~igicas con el objeto de clarificar el estado actual y la estrategia de esta modalidad teraprutica en el Jap6n. Se recolectaron 12.675 casos, inc[uyendo 4.159 de procedimientos no derivativos y 7.612 de escleroterapia, prolvenientes de 101 instituciones. El ndmero de pacientes habfa aumentado notoriamente en la primara mitad de los afios 1980s. Se encontr6 que en relaci6n a la estrategia de tratamiento, no se recomendaron procedimientos quinirgicos en casos de emergencia ni como modalidad profilf~ctica en t~rminos d d momento de realizar la operaci6n, ni en los casos Child C en trrminos del grado de insuficiencia hepfitica. La escleroterapia por inyeeci6n endosc6pica se convirti6 en el mrtodo principal de tratamiento, en tal forma q u e e n 1988 s61o 16% de 1.528 casos fueron tratados quirdrgicamente. Sin embargo, el manejo frente al mismo grupo de pacientes difiri6 entre las instituciones mrdicas y las quirdrgicas. Referente a la escleroterapia, las inyecciones repetidas intravaricosas y combinadas intra y paravaricosas aparecen como las trcnicas principales, con tasa acumulativas de sobrevida a 10 afios de 62.8% en los casos Child A, 47.7% en los Child B y 13.2% en los Child C. En cuanto a los procedimientos

1200

quirttrgicos, las tasas de sobrevida a 10 afios fueron 50.6% para la transeccitn esof~igica, 42.5% para la transeccitn g~tstrica, 53.1% para la cardiectom/a y 43.0% para los "shunts" selectivos. Estamos convencidos que el presente reporte probarA ser titil en la determinaci6n de futuras estrategias para el tratamiento de v~irices esof~igicas. Acknowledgment

We wish to acknowledge all 101 institutions that kindly responded to our survey: Third Department of Medicine, Asahikawa Medical College; First Department of Medicine, Sapporo Medical College; First Department of Surgery and Second Department of Surgery, Hokkaido University; Sapporo Kitanire Hospital; First Department of Medicine, Hirosaki University; First Department of Surgery, Tohoku University; First Department of Surgery, Iwate Medical University; First Department of Surgery, Akita University; First Department of Surgery, Yamagata University; Second Department of Medicine, Fukushima Medical College; Department of Surgery, Kiryu Kousei General Hospital; First Department of Surgery, Gunma University; Department of Surgery and Medicine, The University of Tsukuba; Second Department of Medicine, First Department of Surgery and Second Department of Surgery, Dokkyo University; First Department of Medicine, Chiba University; Second Department of Surgery, Saitama Medical School; Department of Surgery, Komagome Hospital; First Department of Surgery, Nippon Medical School; First Department of Surgery and Second Department of Surgery, University of Tokyo; Second Department of Surgery, Juntendo University; Toshiba Central Hospital; Tokyo Hospital, Tokai University; First Department of Surgery and Second Department of Surgery, Nihon University; First Department of Surgery and Second Department of Surgery, Tokyo Medical and Dental University; First Department of Medicine, First Department of Surgery and Department of Endoscopy, The Jikei University; Third Department of Surgery, Nihon University; Gastroenterological Center, Tokyo Women's Medical College; Second Department of Surgery, Tokyo Women's Medical College; First Department of Medicine, Teikyo University; Department of Surgery, Mizonokuchi Hospital, Teikyo University; Third Department of Medicine, Nihon Medical School; Department of Surgery, Tokyo Medical College; Second Department of Medicine, Showa University; Department of Surgery, Tokyo Metropolitan Police Hospital; Department of Medicine, Fujigaoka Hospital, Showa University; Second Department of Surgery, St. Marianna University; Second Department of Surgery, National Defense Medical College; Second Department of Medicine, Toho University; Third Department of Medicine, Yokohama City University; Department of Surgery, Tokai University; First Department of Medicine, Yamanashi Medical College; Shizuoka General Hospital; National Zentsuji Hospital; Second Department of Medicine, Hamamatsu University; Nagano Central Hospital; Second Department of Surgery, Shinshu University; First Department of Surgery, Niigata University; First Department of Surgery, Gifu University; Second Department of Surgery, Toyama Medical and Pharmaceutical University; First Department of Medicine and Second Department of Surgery, Kanazawa University; First Department of Surgery, Fukui Medical School; Department of Medicine and

World J. Surg. Voi. 16, No. 6, Nov./Dec. 1992

Department of Surgery, Fujita Health University School of Medicine; First Department of Surgery, Aichi Medical University; Second Department of Surgery, Nagoya University; Aichi Cancer Institute; Third Department of Medicine and First Department of Surgery, Mie University; Third Department of Medicine, Kyoto Prefectural University of Medicine; Third Department of Medicine and Department of Surgery, Kansai Medical University; First Department of Surgery, Osaka University Medical School; Department of Surgery, Osaka Medical College; First Department of Surgery, Osaka City University; Department of Medicine, Osaka Tetsudo Hospital; Department of Surgery, Kinki Central Hospital; First Department of Surgery, Second Department of Surgery and Department of Emergency, Hyogo College of Medicine; First Department of Surgery, Okayama University; Department of Surgery, Hiroshima Red Cross Hospital; Department of Surgery, Shimane Central Hospital; Second Department of Surgery and Third Department of Medicine, Ehime University; First Department of Surgery, The University of Tokushima; First Department of Surgery, Kochi Medical School; Second Department of Surgery, Kyushu University; Second Department of Medicine and The First Department of Surgery, Kurume University; First Department of Surgery, Miyazaki Medical College; First Department of Surgery and Second Department of Surgery, Kumamoto University, Also we wish to thank Dr. K. Sanjo and Dr. Y. Harihara for processing the data and preparing the manuscript. References

1. Inokuchi, K.: Present status of surgical treatment of esophageal varices in Japan: A nationwide survey of 3,588 patients. World J. Surg. 9:171, 1985 2. Inokuchi, K.: Prophylactic portal nondecompression surgery in patients with esophageal varices. Ann. Surg. 200:61, 1984 3. Japanese Research Society for Portal Hypertension: The general rules for recording endoscopic findings on esophageal varices. Jpn. J. Surg. I0:84, 1980 4. ldezuki, Y., Sanjo, K., Kawasaki, S., Ohashi, K., Harihara, Y., Sakamoto, H., Koyama, H., Kokudo, N.: Current status of injection sclerotherapy for esophageal varices in Japan (in Japanese). Jpn. Med. J. 3357:24, 1988 5. Idezuki, Y., Sanjo, K., Kawasaki, S.: Current status of injection sclerotherapy for esophageal varices in Japan; Second National Survey in 1988(in Japanese). Jpn. Med. J. 3439:44, 1990 6. Ideznki, Y., Sanjo, K., Bandai, Y., Kawasaki, S., Ohashi, K.: Current strategy for esophageal varices in Japan. Am. J. Surg. 160:98, 1990 7. Beppu, K., Inokuchi, K., Koyanagi, N., Nakayama, S., Sakata, H., Kitano, S., Kobayashi, M.: Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest. Endosc. 27:213, 1981 8. Koyanagi, N., Cooperative Study Group of Portal Hypertension in Japan: Prognostic blue varices as a discriminant factor of findings of esophageal varices. Jpn. J. Surg. 18:142, 1988 9. Inokuchi, K., Sugimachi, K.: The selective shunt for variceal bleeding: A personal perspective. Am. J. Surg. 160:48, 1990 10. Warren, W.D., Millikan, W.J., Henderson, J,M., Abu-Elmagd, K.M,, Galloway, J.R., Shire, G.T., Richards, W.O., Salam, A.A., Kutner, M.H.: Splenopancreatic disconnection: Improved selectivity of distal splenorenal shunt. Ann, Surg. 204:346, 1986 11. Inokuchi, K., Beppu, K., Koyanagi, N., Nagamine, K., Hashizume, M., Sugimachi, K.: Exclusion of non-isolated splenic vein in distal splenorenal shunt for prevention of portal malcircutation. Ann. Surg. 200:711, 1984 12. Bismuth, H., Adam, R., Mathur, S., Sherlock, D.: Options for elective treatment of portal hypertension in cirrhotic patients in the transplantation era. Am. J. Surg. 160:105, 1990